Inspection on 19/12/06 for The Queensmead

This inspection was carried out on 19th December 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

The Queensmead 17/11/08

The Queensmead 23/01/06

The Queensmead 23/08/05

The Queensmead 21/02/05

The Queensmead 31/08/04

The Queensmead 19/12/03

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE The Queensmead Victoria Road Polegate East Sussex BN26 6BU Lead Inspector Rebecca Shewan Key Unannounced Inspection 19th December 2006 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address The Queensmead DS0000021260.V324642.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. The Queensmead DS0000021260.V324642.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Queensmead Address Victoria Road Polegate East Sussex BN26 6BU Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01323 487931 01323 488120 madeleinemarshall@hotmail.com Chanctonbury Healthcare Limited Mrs Madeleine Marshall Care Home 37 Category(ies) of Old age, not falling within any other category registration, with number (37) of places The Queensmead DS0000021260.V324642.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The maximum number of service users to be accommodated is thirtyseven (37). Service users should be sixty-five (65) years or over on admission. Date of last inspection 23rd January 2006 Brief Description of the Service: The Queensmead is registered to provide personal care for up to 37 older people, over 65 years of age. The home is situated in a residential area of Polegate, close to the town’s high street with shops, the library and public transport within walking distance. There is a large lounge that is used for social activities, a separate dining room, a conservatory at the front of the building and smaller seating areas near the reception and on the first floor. There are 35 bedrooms in the home arranged over three floors; 33 of which are single occupancy (of which all have en-suite facilities) and 2 of which are double occupancy: one is arranged as a self contained flat providing accommodation for married couples (both double occupancy areas have en-suite facilities). Additional toilet and bathroom areas are available throughout the premises. Appropriate aids are provided including hoists and assisted baths and toilets. A shaft lift enables residents to have access to all parts of the building. There are attractive gardens surrounding the home that are accessible to wheelchair users and is used by residents and staff when the weather permits, with additional seating areas to the front of the building. There is also a parking area to front of the building. Potential new service users can obtain information relating to the home via CSCI Inspection Reports, Care Managers, Placing Authorities, the internet by word of mouth and by contacting the home direct. The range of fees charged (at the time of this report) are £400 - £560 per week, with additional charges made for hairdressing and chiropody. The Queensmead DS0000021260.V324642.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place during the morning and afternoon of the 19th December 2006. Incident reports, previous inspection reports and the home’s Pre-Inspection Questionnaire, held by the Commission for Social Care Inspection, were read before the inspection. The inspection of the home took six and a quarter hours. A tour of the whole home was undertaken and the Registered Manager, four staff and five service users (known as residents), were spoken with. Records such as care plans, maintenance records and medication records were also viewed. Ten Service User Surveys were distributed of which ten were returned. Comments received included: ‘I like living here, it is very homely’ ‘I am encouraged to be independent and I like that’ ‘The staff here are excellent and respect my privacy’ ‘Most days the food is very good’ The home were requested to complete a Pre-Inspection Questionnaire, which was returned in a timely manner. Thirty five residents were accommodated at the home at the time of the inspection. NB: As part of this unannounced inspection the quality of information given to people about the care home was looked at. People who use the service were also spoken to, to see if they could understand this information and how it helped them to make choices. The information included the Service Users Guide (sometimes called a brochure or prospectus), Statement of Terms and Conditions (also known as Contracts of Care) and the Complaints Procedure. These findings will be used as part of a wider study that CSCI are carrying out about the information that people get about care homes for older people. This report will be published in May 2007. Further information on this can be found on our website www.csci.org.uk. The Queensmead DS0000021260.V324642.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: The Queensmead DS0000021260.V324642.R01.S.doc Version 5.2 Page 7 The home must ensure that urgent action is taken to ensure the health, safety and welfare of residents and staff at all times in that all handwritten entries onto MAR sheets must be signed by two staff and an explanation for the handwritten entry entered onto the back of the MAR sheet, that daily medication fridge temperatures must be maintained and recorded, that communal bars of soap and non disposable hand towels must be removed in order to reduce the risk of cross infection, that the hairdressing and boiler room doors must be kept shut and locked at all times of being unoccupied in order to prevent the risk of hazard to both service user’s and staff and that portable liquid soap dispensers must be risk assessed according to the current service users or removed. The home must ensure that that the Statement of Purpose and Service User Guide is updated to include that the homes correct management structure, the correct range of fees charged and to detail that the home is registered with the CSCI as opposed to the former NCSC. Once produced an updated copy of both documents must be made available to all new and existing residents, in order to ensure that they are in receipt of the most current information relating to the service. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. The Queensmead DS0000021260.V324642.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Queensmead DS0000021260.V324642.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 & 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has processes in place for assessing potential new resident’s with services being offered to only those resident’s whose needs can be met. However, some improvement is required to ensure that the information conveyed to new and potential new residents is current. EVIDENCE: It was evidenced that a copy of the Statement of Purpose and Service users’ Guide is displayed within the home. However it was noted that the Statement of Purpose detailed the incorrect range of fees charged, that the home employs a Restaurant Manager (who is no longer with the service) and that the home is registered with the NCSC as opposed to the CSCI; therefore both documents require updating. Three residents were asked whether they had been given a copy of both the Statement of Purpose and Service User Guide and they commented that they ‘had seen them in the past’ but they had been given to The Queensmead DS0000021260.V324642.R01.S.doc Version 5.2 Page 10 their friend/relative/representative prior to their admission to the home and that these documents were in their friend/relative/representative possession. Residents contracts were viewed and these were found to be comprehensive and detailed in content. Of those documents viewed it was evidenced that the resident’s and/or their representative or placing officer had signed their contract. Three residents were asked whether they had been given a copy of their contract and all three responded that they had not dealt with this matter as their friend/relative/representative had dealt with this matter on their admission and that these documents were in their friend/relative/representative possession. The home’s Registered Manager carries out pre- admission assessments. The home obtains a copy of a care management assessment from a placing authority where this exists. The Registered Manager reported that any issues, which are highlighted within this assessment, are addressed by the home and documented records are maintained of all correspondence with the placing authority. Records inspected showed that pre- admission assessments are carried out on all new and potential residents. Residents confirmed that they had been involved in the assessment process and had felt included in their admission to the home. Intermediate care is not offered by this home. The Queensmead DS0000021260.V324642.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are offered a good provision of health care and personal support by the home. However improvements are required to ensure that medication records are maintained appropriately in order to prevent the risk of errors being made by staff when administering medication to residents. EVIDENCE: Four residents individual care plans were viewed and it was noted that these were detailed in content and covered all aspects of resident’s needs. Residents informed the inspector that care plans are devised with their involvement. It was also noted that details of any specialist interventions required e.g. for the management of nutrition, pressure area care and wound dressings are specified and recorded in residents care plans. Suitable risk assessments were also found to be in place. Documented records viewed supported this. The home has made improvements since the inspection of January 2006 to ensure that training has been provided for all staff to ensure continuity of information is recorded in the care plans. This was evidenced from the care plans viewed. The Queensmead DS0000021260.V324642.R01.S.doc Version 5.2 Page 12 From the records sampled and from discussions with staff, it was evidenced that the health needs of residents are well met with evidence of good multi disciplinary working taking place, on a required basis. The Registered Manager said that residents can be registered with a GP of their own choice or one from any of the local surgeries. Resident’s are encouraged to attend the GP surgery were able and home visits are conducted when necessary. Referrals to the Occupational Therapist, Physiotherapist, Dietician and Audiologist are made via the GP or the hospital. The home has access to pressure relieving equipment. The home has good procedures in place for the monitoring and recording of all drugs entering and leaving the home. The stores for medication were viewed and these were found to be maintained in a clean and orderly manner. However, the medication administration record (MAR) sheets were viewed and it was evidenced that some improvements are required, to address the manner in which staff record medications either administered or non- administered. Some handwritten entries were also noted and it was evidenced that these were unsigned, undated and that no explanation had been given on the back of the MAR sheet. Daily medication fridge temperatures were found not to be recorded. Therefore immediate statutory requirements were made. Staff were observed providing personal support to service users in such a way that promoted and protected residents privacy and dignity. Residents spoken with said that care staff were ‘kind, patient and respected privacy at all times’. The Queensmead DS0000021260.V324642.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides good social, cultural and recreational facilities, including a specialist diets to residents, with resident’s choice and wishes being respected. EVIDENCE: Residents said that they enjoyed many of the home’s activities and that the home staff were flexible in allowing residents to choose the level of activities attended. A published list of activities is made available to residents, with residents being informed of special events being held in the home. Activities include: arts and crafts, Pat Dog, sing a longs, quizzes, bingo, a variety of external musicians, exercise classes and reminiscence therapy. Of the ten service user surveys received five responded always, two responded usually and one responded sometimes to the question that asks ‘are there activities arranged by the home that you can take part in?’ One resident commented that ‘activities can be difficult to attend due to my deafness but I am encouraged to pursue my own interests such as reading, writing and attending the local library’. Resident’s religious wishes are observed and arrangements are in place for residents to receive Holy Communion if they wish. Discussions with the The Queensmead DS0000021260.V324642.R01.S.doc Version 5.2 Page 14 Registered Manager highlighted that although the current residents fell into a specific age group and had similar religious beliefs, the home would welcome any potential new resident who has special cultural/religious/spiritual beliefs and would make provision to accommodate their needs. The home believes in promoting an equal and diverse culture among staff and residents. Contact with family and friends is positively encouraged with visitors being able to attend the home at any time and in accordance with the resident’s wishes. Residents spoken with confirmed this. Residents are treated with respect and there is a good rapport between staff of the home and residents. This was observed at the time of the inspection. Residents reported that the home assists them to maintain their independence with their daily living and daily routines. The home’s menus are devised on a three week rolling programme. The menus viewed showed that there is a variety of food and that the menus are varied. All meals are home cooked with an alternative option available for each mealtime. Mealtimes can be varied upon request and patient’s guests are also welcome to have meals at the home. Medical, therapeutic or religious diets are provided as needed. Drinks and snacks are available at all times. The meal served during the inspection was ample in quantity and attractively presented. Mealtimes were observed to be unhurried. Staff were observed assisting with feeding residents in a dignified and unhurried manner. Residents spoken with reported that ‘the food is very good here, we often get too much!’, ‘we like the food it is usually very good’ and ‘the food is excellent!’. The Queensmead DS0000021260.V324642.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident’s benefit from a robust and efficient complaints procedure, whilst the homes procedures, processes and staff training should protect resident’s in the event of an allegation of abuse. EVIDENCE: The home has an established complaints procedure in place. The home has received one complaint within the past twelve months, which had been recorded as addressed within the response time specified by the home’s policies and procedures. The complaint has now been resolved and appropriate action was taken by the home to address the concerns raised. From the section in the service user surveys received relating to complaints, this showed that three ‘always’ knew who to complain to and one ‘usually’ knew who to complain to. One did not respond. Whilst five responded ‘no – have no need to complain’. Three residents were asked whether they knew about the homes complaint procedure and whether they had a copy of this document, all three commented that ‘they had seen it but it is looked after by my friend/relative/representative’. Following the inspection of January 2006 training in Adult Protection and whistle blowing has been provided for all staff. Criminal Record Bureau (CRB) checks have been carried out on all existing staff. Both CRB and Protection of Vulnerable Adult (POVA) checks are carried out on all new staff. Staff have The Queensmead DS0000021260.V324642.R01.S.doc Version 5.2 Page 16 attended training in the Protection of Vulnerable adults within the last twelve months. This was evident from the staff files that were viewed and from staff spoken with during the inspection process. Staff said that they were confident that in the event of an allegation of abuse, they would know the correct procedure to follow. The home has a copy of the East Sussex County Council Multi-agency Procedures for the Protection of Vulnerable Adults. There have been no Adult Protection Alerts in the last twelve months. The Queensmead DS0000021260.V324642.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides accommodation for residents that is safe, hygienic and odour free, with some improvement required to ensure that infection control procedures are adhered to at all times. EVIDENCE: The location and layout of the home are suitable for its stated purpose. The home is well maintained and all areas of the home, including the garden, are accessible to residents. The home has an ongoing plan of refurbishment in place. Residents spoken with said that they liked their bedrooms and that the communal areas of the home were comfortable and decorated nicely. The home has an infection control policy in place and staff are trained in infection control procedures, this was confirmed by staff training records and by staff spoken with. However it was evidenced that a number of the homes toilet and bathroom areas had non- disposable hand towels and bars of soap in The Queensmead DS0000021260.V324642.R01.S.doc Version 5.2 Page 18 them. The infection control implications of these items were discussed with the Registered Manager and an Immediate Statutory Requirement was made. It was noted that a clinical waste contract is in place. Of the ten service user surveys received six responded always, three responded usually and one did not respond to the question that asks ‘Is the home fresh and clean?’. The Queensmead DS0000021260.V324642.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a staff team that have the necessary skills and experience to the meet the needs of current residents. EVIDENCE: A competent staff team meets the resident’s needs. There is a staff rota in place, which details staff designations and hours of working. Of the ten service user surveys received one responded always, eight responded usually and one responded sometimes to the question that asks ‘Are the staff available when you need them?’. Residents commented on the surveys that bells are sometimes answered more slowly if the staff are already answering an emergency call from another person but routine service by permanent staff is very good’ and that ‘the home is blessed with a high proportion of excellent staff numbers who are experienced, kind and friendly’ The home has a permanent care staff team of twenty one carers, four of which are trained in National Vocational Qualification (NVQ) level 2 or 3 in care. Whilst a further five carers undertaking the training at the current time. This was confirmed in the homes Pre-Inspection Questionnaire and from staff training records viewed. The Queensmead DS0000021260.V324642.R01.S.doc Version 5.2 Page 20 Staff recruitment files were viewed and it was evidenced that these files contain all items required under the Care Homes Regulations 2001.The home has an Equal Opportunities policy in place and is an equal opportunities. Following the inspection of January 2006 the home has made improvements to ensure that induction training conducted is in line with Skills for Care. Staff training records showed that over the last twelve months the home had provided a range of training, including Induction Training, Fire Training, Health and Safety, Moving & Handling, Medication, Nutrition, Risk Assessing and First Aid. The Queensmead DS0000021260.V324642.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management and administration of the home is good, with evidence of consideration being given to resident’s choice and opinion, with urgent improvement required to ensure that the health, safety and welfare of residents and staff is being protected at all times. EVIDENCE: The Manager has many years relevant experience in caring for older people and has achieved the NVQ level qualification in Management. Residents and staff spoken with said that the Manager is friendly, knowledgeable and approachable. The Queensmead DS0000021260.V324642.R01.S.doc Version 5.2 Page 22 Following the inspection of January 2006 the home has made improvements to ensure that a quality assurance and monitoring system has been developed and introduced. There is a now a Quality Assurance policy in place, that involves an annual development plan and continual self-monitoring of the home by the Organisation. Quality Assurance questionnaires are distributed to residents, their representatives and other interested parties. The results of which are not published but are made available to all upon request. Monthly unannounced (Regulation 26) visit reports are conducted and copies of these reports are available for CSCI inspections. Staff and residents meetings are held, the minutes of which were viewed and were found to be detailed in content and included actions taken to address previous issues raised by staff and residents. The Manager reported that the home does not take any responsibility for any of the resident’s other finances and that most residents have family, friends or representatives who protect their financial affairs. Any monies held on behalf of the residents by the home, known as pocket money accounts, are appropriately maintained, with detailed records kept of all transactions made to and from each account and evidence of an annual audit of these records having been conducted. Following the inspection of January 2006 the home has made improvements to ensure that advice has been sought, and acted upon, from the Fire Service concerning the use of safe systems of keeping doors to residents’ bedrooms open. From the Pre-Inspection Questionnaire provided by the home and from records viewed it was evident that fire drills, fire alarm testing and fire equipment checks, water checks and Portable Appliance Testing (PAT) had been carried out. Accidents are well documented in the home’s accident book. However, it was evident that the hairdressing and boiler room doors were unlocked and easily accessible despite clear signs stating ‘must be kept shut and locked’. The hairdresser’s room was found to contain a box of hair styling products. It was evidenced that these products were not maintained in accordance with Control Of Substances Hazardous to Health (C.O.S.H.H) thereby increasing the risk of hazard to both residents and staff. It was also noted, during the tour of the premises, that in some of the homes bathroom and toilet areas portable liquid soap dispensers were in use and it was noted that these had not been risk assessed or removed (if appropriate) for the current residents. Therefore Immediate Statutory Requirements were made. The Queensmead DS0000021260.V324642.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 The Queensmead DS0000021260.V324642.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP1 Regulation 4 (a) (c) Sched 1 Requirement That the Statement of Purpose and Service User Guide must be updated to include that the homes correct management structure, the correct range of fees charged and that the home is registered with the CSCI. An updated copy of both documents must be made available to all new and existing residents. That all handwritten entries onto MAR sheets must be signed for by two staff, dated and sourced. This is an immediate requirement. That daily medication fridge temperatures must be maintained and recorded. This is an immediate requirement. Timescale for action 19/02/07 2. OP9 13 (2) 19/12/06 3. OP9 13 (2) 19/12/06 4. OP26 13 (3) & That communal bars of soap and (4) (a) (b) non-disposable hand towels (c) must be removed. This is an immediate requirement. 13 (4) (a) (b) (c) That the hairdressing and boiler room doors must be kept shut and locked at all times of being DS0000021260.V324642.R01.S.doc 19/12/06 5. OP38 19/12/06 The Queensmead Version 5.2 Page 25 unoccupied. This is an immediate requirement. 6. OP38 13 (4) (a) (c) 09/01/07 That portable liquid soap dispensers must be risk assessed according to the current service users or removed. This is an immediate requirement. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations The Queensmead DS0000021260.V324642.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI The Queensmead DS0000021260.V324642.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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